U.S. patent number 5,354,292 [Application Number 08/024,934] was granted by the patent office on 1994-10-11 for surgical mesh introduce with bone screw applicator for the repair of an inguinal hernia.
Invention is credited to Harry L. Braeuer, James L. Youngblood.
United States Patent |
5,354,292 |
Braeuer , et al. |
October 11, 1994 |
**Please see images for:
( Certificate of Correction ) ** |
Surgical mesh introduce with bone screw applicator for the repair
of an inguinal hernia
Abstract
A surgical device particularly directed toward the endoscopic
repair of inguinal hemas is disclosed. The device includes of a
specially adapted surgical mesh and a mechanical means for
attaching the surgical mesh to the pubic bone. The surgical mesh is
mechanically attached to the pubic bone by an orthopedic screw and
the peripheral margins of the mesh either sutured or stapled to the
appropriate anatomical structures. The screw is held by the distal
end of an inner tube which is positioned inside an outer tube
providing an annular space therebetween. The surgical mesh is
wrapped around the distal end of the inner tube and the screw and
is held in place in the annular space. An actuator tool is placed
in the inner tube to provide torque to the screw.
Inventors: |
Braeuer; Harry L. (Seabrook,
TX), Youngblood; James L. (Houston, TX) |
Family
ID: |
21823116 |
Appl.
No.: |
08/024,934 |
Filed: |
March 2, 1993 |
Current U.S.
Class: |
606/1; 606/104;
606/151 |
Current CPC
Class: |
A61B
17/068 (20130101); A61B 17/076 (20130101); A61B
17/8891 (20130101); A61F 2/0063 (20130101); A61B
17/00234 (20130101); A61F 2002/0072 (20130101) |
Current International
Class: |
A61B
17/88 (20060101); A61F 2/00 (20060101); A61B
17/068 (20060101); A61B 17/03 (20060101); A61B
17/076 (20060101); A61B 17/12 (20060101); A61B
17/00 (20060101); A61B 017/00 () |
Field of
Search: |
;606/65-67,72-75,86,96,99,100,104,151,213,232,1 |
References Cited
[Referenced By]
U.S. Patent Documents
Foreign Patent Documents
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0827050 |
|
May 1981 |
|
SU |
|
1053820 |
|
Nov 1983 |
|
SU |
|
Other References
Stryker Screw Driver p. 33 of Fracture Appliances Feb. 1,
1947..
|
Primary Examiner: Pellegrino; Stephen C.
Assistant Examiner: Dawson; Glenn K.
Attorney, Agent or Firm: Arnold, White & Durkee
Claims
What is claimed is:
1. Apparatus for repairing an inguinal hernia, comprising:
a) an outer sleeve including a distal end positionable within a
patient proximate an inguinal hernia and the pubic bone, and a
proximal end adapted to extend through an incision in the
patient;
b) an inner sleeve having distal and proximal ends corresponding to
said distal and proximal ends of said outer sleeve, said inner
sleeve positioned within the outer sleeve and defining an annular
space between said outer sleeve and said inner sleeve:
c) a piece of surgical mesh stored within said annular space, a
portion of said piece of surgical mesh covering said distal end of
said inner sieve:
d) a surgical fastener positioned proximate said distal ends of
said inner and outer sleeves and coupled to said piece of surgical
mesh, said surgical fastener being actuatable to fasten said piece
of surgical mesh to the pubic bone; and
e) a fastener actuating tool inserted within said inner sleeve,
said fastener actuating tool having a distal end configured to
engage said surgical fastener, and a proximal end adapted to
receive and transmit actuating power to said surgical fastener to
fasten said piece of surgical mesh and said surgical fastener to
the cubic bone.
2. The apparatus of claim 1, wherein said surgical fastener
comprises a surgical screw.
3. The apparatus of claim 2, which further comprises a supporting
member at said distal end of said inner sleeve to support said
surgical screw prior to actuation by said fastener actuating
tool.
4. An apparatus for repair of an inguinal hernia, comprising:
a) an outer sleeve having a distal end portion positionable
opposite an inguinal hernia and a proximal end portion adapted to
extend through an incision in a patient;
b) an inner sleeve positioned within said outer sleeve and defining
an annular space between said inner sleeve and said outer sleeve,
said inner sleeve having a distal end portion proximate said distal
end portion of said outer sleeve;
c) a surgical screw protruding from said distal end portion of said
inner sleeve and adapted to be driven from said inner sleeve;
and
d) a surgical mesh positioned within said annular space and
extending over said distal end portion of said inner sleeve and
said surgical screw.
5. Apparatus for repairing an inguinal hernia, comprising:
a first cannula having a distal end and a proximal end, said distal
end holding of a surgical screw with a pointed end of said surgical
screw directed outward from said distal end;
a piece of surgical mesh covering said distal end of said first
cannula and said pointed end of said surgical screw held within
said distal end of said first cannula;
a second cannula adapted to receive said distal end of said first
cannula and defining an annular space therebetween, said annular
space containing said piece of surgical mesh: and
a screw driver positioned within said first cannula and having two
ends, said screw driver adapted at one end to engage a head of said
surgical screw held within said distal end of said first cannula,
and adapted at another end to extend beyond said proximal end of
said first cannula, said other end being further adapted to receive
and transmit actuating power to said surgical screw.
Description
FIELD OF THE INVENTION
The present invention relates generally to a surgical instrument
and more particularly to a surgical instrument and methods for use
in the repair of an inguinal hernia.
BACKGROUND OF THE INVENTION
A hernia is the formation of an opening in the abdominal wall
typically accompanied with abdominal tissue and viscera which push
through the opening in the abdominal wall. The abdominal wall has
several relatively weak regions where hernias tend to occur with
greatest frequency. These include: 1) the internal inguinal ring
where an indirect hernia occurs, 2) Hesselbach's triangle where a
direct hernia occurs, and 3) the femoral ring where a femoral
hernia occurs. Each of these defects is considered an inguinal
hernia.
A femoral hernia forms in the femoral ring in the iliopubic tract
spanning the gap between the inguinal ligament and the pubic bone.
This conforms to the space between the femoral vessels and the
pubic bone beneath the inguinal ligament.
A direct hernia is the result of weakness of the transversalis
fascia that forms the floor of the Hesselbach's triangle. The
Hesselbach triangle is bordered by the conjoined tendon and edge of
the rectus sheath medially, the inguinal ligament at the base, and
the inferior epigastric artery laterally and superiorly. The
functional lateral and superior border of the direct hernia is
actually the edge of the transversus abdominis muscle.
An indirect inguinal hernia is situated adjacent the direct hernia;
the two being separated by the inferior epigastric artery. Unlike
the other two hernias, the indirect hernia is the result of a
congenital flaw. A sac of peritoneum follows the testis in its
descent through the inguinal ring and into the scrotum during
development. Normally, the sac seals itself as it passes through
the internal ring.
The treatment of an inguinal hernia frequently involves surgery in
an effort to repair the defect. In most inguinal hernias, abdominal
tissue has pushed through a defect in the abdominal wall. Normally,
the abdominal tissue forms a sac lined by the peritoneum with
viscera contained in the sac. Treatment requires that the contents
of the sac be returned to their normal position in the abdomen and
the defect in the abdominal wall surgically repaired by suturing
the ruptured fascia at the site of the defect in an effort to close
and restore the integrity of the abdominal wall.
Conventional procedures for hernia repair may provide only
temporary relief. Typically, they involve stretching of the
musculature and ligamentous tissue in order to close the defect.
The tissues are sutured while in a stretched configuration which
makes the abdominal wall further susceptible to a recurring hernia.
Thus, surgical correction of a recurring hernia often results in
further degeneration of the involved fascia, muscles, and
ligaments.
In an effort to avoid recurring hernias and the resulting
progressive deterioration, surgeons commonly use implantable mesh
material to repair the defect. A sheet of surgical mesh material,
usually polypropylene or Gore-rex.TM., is placed over the defect
and sutured in place as determined by the surgeon. A single sheet
of surgical mesh, generally 3.times.5 inches in size, may be used
to cover all three inguinal defects. Although some hernias may be
successfully treated in this manner, others result in failure and
recurrence of the hernia.
Endoscopic surgery has been a major improvement in the field of
orthopedics, gynecology and general surgery because surgical
procedures can be performed in a less invasive manner than
previously possible. The surgeon performing an endoscopic procedure
will make two to three small incisions rather than one large
incision. He then uses an endoscopic camera to view the interior
anatomy of the patient. He directs surgical instruments through the
incisions not occupied by the camera to the surgical site and
performs the surgical procedure. The use of smaller incisions
requires that less muscle tissue be cut than when a single large
incision is required. Generally, endoscopic procedures
significantly reduce the surgical trauma to the patient and
consequently reduce the recovery time that the patient
requires.
While endoscopic surgery has been quite successful in dealing with
many problems, it has not been as successful in the treatment of
inguinal hernias. Using the endoscopic pre-peritoneal approach, a
single 3.times.5 inch sheet of mesh may be used to cover all three
inguinal detects. A problem arising with the endoscopic or
laparascopic approach has been the lack of a predictably effective
method of attaching surgical mesh to the tissues proximate to the
pubic bone, an area commonly the site of recurrent hernias.
Generally, in open surgical procedures for inguinal hernias where
surgical mesh has been used, the mesh has been sutured to Cooper's
ligament which is attached to the pubic bone. Cooper's ligament is
a very tough, fibrous ligament offering good retention of mesh
properly sutured to it. Endoscopically, surgical mesh has generally
been attached by use of endoscopic staples. Endoscopic staples,
however, have not proven to be predictably effective to attach
surgical mesh to Cooper's ligament, thereby resulting in recurrence
of hernias in the area proximate the pubic bone.
To complete existing procedures using mesh for repairing inguinal
hemas, the remaining margins of the surgical mesh have been
generally attached to surrounding tissue by endoscopic stapling.
This portion of the procedure in endoscopic hernia repair has not
proven to be as great a problem because recurrence of a hernia
predominately occurs in the region of the pubic bone.
SUMMARY OF THE INVENTION
The present invention in a general aspect comprises a system for
installing surgical mesh within the body by mechanically fastening
a portion of the mesh to a bone and attaching other portions of the
mesh to body pans by suturing or stapling. Mechanical fasteners
include surgical screws, staples, and other suitable metallic or
plastic devices. In the present invention, surgical screws are
preferred for fastening mesh to the pubic bone because of their
greater reliability and their ease of installation, especially in
endoscopic surgical procedures.
The present invention has particular application in repairing
inguinal hernias, including direct, indirect, and femoral hemas. In
these instances, a section of surgical mesh is fastened to the
pubic bone by means of a mechanical fastener, and it is also
fastened by means such as sutures or staples to fascia, muscles and
ligaments. The invention has application in both endoscopic and
open surgical procedures, but especially in endoscopic procedures.
In all such procedures a mechanical fastener is positioned through
a cannula proximate a portion of the pubic bone and at a point near
the hernia. A portion of a surgical mesh is interposed between the
mechanical fastener and the pubic bone, and the fastener is then
screwed or otherwise driven into the bone to anchor the mesh. A
suitable driving tool is preferably directed through the cannula
against the fastener, and a driving force (axial or torsional) then
applied to the fastener.
Tools useful in the invention may vary in particular features,
depending on such factors as the type of fastener and the surgical
procedure employed. In a general aspect, the tools comprise a
dispenser or other suitable holder for holding a mechanical
fastener in position opposite the pubic bone and proximate an
inguinal hernia. The tools also comprise a suitable driving member
which is actuatable to drive the fastener from the holder into the
pubic bone.
When referring to the use of the present invention, distal is used
to mean that portion of the device farthest from the operator and
closest to the interior or center of a patient, while proximal is
meant to refer to that portion of the device nearest to the
operator and farthest from the interior or center of a patient.
In one aspect of the invention, the fastener holder may comprise a
cannula or other suitable sleeve member adapted to hold a fastener
at one end such that the fastener may be displaced from the sleeve
member into the pubic bone. This type of holder has been found to
be especially useful in endoscopic procedures with surgical screws
as mechanical fasteners. A screw driver with an elongated shank is
passed down the sleeve member to engage the head of the screw. The
handle of the screw driver protrudes from the opposite (or
proximal) end of the sleeve member. The surgeon then operates the
handle so as to drive the screw from the sleeve member into the
pubic bone. The screwdriver may be operated either manually or
mechanically.
In another aspect of the invention, the holder may comprise a
specially adapted head which is preferably sized to pass through a
cannula or sleeve member so as to be positioned opposite the pubic
bone and proximate an inguinal hernia. The head may be adapted to
hold and dispense various mechanical fasteners, and it may be used
with various driving tools. One especially preferred head comprises
a generally cylindrical or disk-like member which is recessed and
configured at one end to hold a staple with the ends of the staple
facing away from the head, i.e., toward the pubic bone. The
recessed portion of the head is configured to hold the staple
firmly in position. The head, meanwhile, is made sufficiently
flexible such that proximal movement of the central portion of the
head relative to the peripheral portion of the head closes the
recess sufficiently to grasp the staple. A sharp axial force may
then be applied to the proximal end of the head so as to drive the
grasped staple into the bone. The axial force may be delivered to
the head through a rod which extends from the head to a position
where the surgeon may apply an impact to the proximal end of the
rod.
As mentioned earlier, it is a primary purpose of the invention to
mechanically fasten or anchor a piece of surgical mesh to the pubic
bone. To this end, the mesh may simply be placed between the
fastener and the bone in a manner similar to conventional open
surgery. Preferably, and especially in endoscopic surgery, the mesh
is assembled with a mechanical fastener and moved into position
along with the fastener. Thus, the mesh is preferably folded or
otherwise compressed and held in that condition until ready for
application to a hernia. The mesh is then released and expanded to
cover the areas to be repaired.
The folded or otherwise compressed mesh is preferably positioned in
an annulus surrounding the tool employed to drive a fastener. Thus,
a first or outer sleeve through which the driving tool
(screwdriver) passes may be coaxial with a larger diameter outer
sleeve. An annular chamber is thereby formed between the inner and
outer sleeves at the distal end providing an enclosure into which
the mesh is packed.
The mesh, itself, may comprise any suitable surgical mesh such as
polypropylene, polyethylene, Gore-tex.TM. or the like. The mesh
preferably is provided with one or more flexible structural members
such as stays, struts, seams, or the like which help expand the
mesh upon release of the mesh from its place of storage. The
structural members approach the mesh itself in flexibility so as to
be foldable with the mesh, but are sufficiently strong or have
sufficient structural memory to help unfold and position the
mesh.
Once a fastener has been driven into the pubic bone, the mesh may
be released and expanded simply by moving the apparatus of the
invention, i.e., the sleeve or sleeves, away from the bone, such
that the fastener drags the mesh from its container.
Positioning of the structural members on the mesh, as well as the
shape of the mesh, is preferably such that the mesh conforms to the
shape of the patient's anatomy in which the mesh resides. It is
desirable that the mesh cover the area of interest and also extend
to those ligaments, muscles, or the like to which the mesh is to be
sutured or stapled. A preferred mesh design is one which comprises
two polypropylene structural members positioned on the mesh such
that when the mesh is removed from the cannula, the structural
members help urge the mesh into a position conforming to the
proximate anatomy.
BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1A is a longitudinal cross-sectional view of the surgical
screw embodiment of the invention.
FIG. 1B is a view of the surgical mesh.
FIG. 2 is a view in partial section showing the device on a larger
scale illustrating the position of the surgical screw and inner
sleeve in relation to the outer sleeve.
FIG. 3 is a perspective view of the staple-driver device with a
section removed to shorten the length of the drawing.
FIG. 4 is a perspective view of the staple-extractor device with a
section removed to shorten the length of the drawing.
FIG. 5 is a perspective view, partly in phantom, showing the head
of the staple driver-extractor device in a larger scale shown
grasping a staple.
FIG. 6 is a side elevational view of a Richards bone staple.
FIG. 7A is a larger scale side elevational view of the head of the
staple driver-extractor device showing the device in a
staple-release mode.
FIG. 7B is a larger scale side elevational view of the staple
driver-extractor device showing the device in a staple-grasping
mode (deflection exaggerated for clarity).
FIG. 8A illustrates inguinal anatomy as viewed through a
laparascope.
FIG. 8B illustrates the placement of the surgical mesh attached by
surgical screw to the pubic bone overlying three hernia
defects.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
The present invention exists in several embodiments as illustrated
by FIG. 1A through FIG. 6. Referring to the drawings, FIG. 1A
illustrates a preferred embodiment of the invention. The apparatus
comprises an outer sleeve 10 and an inner sleeve 12. Within the
inner sleeve is disposed a shaft 14. The shaft has a first end
portion 16 which is configured as a Woodruff head screwdriver. The
shaft has a second end portion 18 which has a hexagonal driver
attached. Between the outer sleeve and inner sleeve is an annular
space 20. Attached to the outer surface of the inner sleeve is a
spacer 22 which fills a portion of the annular space. Because the
spacer does not extend the entire length of the inner sleeve, the
annular space remains between the outer and inner sleeves in the
first end portion of the device. Within this annular space is
disposed a surgical mesh 24 which is positioned over the end of the
inner sleeve.
FIG. 1B illustrates a specially modified surgical mesh useful in
this operation. A standard piece of 3.times.5 inch surgical mesh is
used to fabricate the specially modified surgical mesh. The
material typically used is polypropylene; however, Gore-tex.TM. or
other suitable surgical mesh material may also be used. The
surgical mesh 32 is properly configured by cutting a portion of the
mesh off the lower fight hand comer. This cut takes a specific path
which begins at about the mid-point of the lower edge of the mesh
and continues upward in an arc ending on the fight hand edge of the
mesh, leaving approximately two-thirds of the mesh on the fight
hand side. This cut is made to conform the mesh to the blood
vessels in the area of the inguinal hernia so that when the mesh is
placed, the mesh will not impinge on these vessels. A structural
member 34 is made to extend diagonally from the lower left comer to
the upper fight comer, being set approximately one-half inch in
from each comer. Structural member 36 is set parallel to the left
edge of the surgical mesh, being positioned approximately
one-quarter of an inch in from the left edge of the mesh; one end
of the structural member 36 being about one-eighth of an inch in
from the top edge of the mesh, and the other end of the structural
member 36 being positioned so as to form about a 45.degree. angle
with structural member 34. The structural members are made of
polypropylene; however, any other material compatible with both the
surgical mesh and the human body would be acceptable. The
structural members are sewn to the surgical mesh; however, they may
also be attached by other acceptable means.
As previously stated, the structural members are disposed on the
surface of the surgical mesh in the approximate form of a
45.degree. angle. When positioned within the first end portion of
the surgical device, an orthopedic screw preferably goes at the
apex of the angle formed by the structural members.
When the surgical mesh is mechanically fastened to a patient's
pubic bone by means of the orthopedic screw, the inner sleeve and
the outer sleeve are removed from the surgical area, allowing the
surgical mesh to unfold aided by the structural members.
FIG. 2 is an enlargement of the first end portion of the device of
FIG. 1A. The first end portion of the outer sleeve is preferably
configured with serrations 26 for placement against a patient's
pubic bone. As previously stated, an annular space 20 exists
between the outer sleeve 10 and the inner sleeve 12 housing a
surgical mesh which is not illustrated here. The first end portion
of the inner sleeve is adapted to receive a screw retaining means
28. The screw retaining means may be a washer or other device
configured for retaining a screw. In a preferred embodiment, the
washer is polypropylene; however, it can be of another material
compatible inside the human body. (A second larger washer, not
shown, may be used to secure the flexible mesh over a larger area.)
The screw retaining means retains a sharpened, Woodruff orthopedic
screw 30. In use, the first end portion of the shaft 16 configured
as a Woodruff screwdriver engages the head of the surgical screw
and drives the screw into the pubic bone of the patient. As
previously stated, the surgical mesh which resides within the
annular space in the first end portion of the device is draped over
the first end portion of the inner sleeve and also over the
sharpened end of the orthopedic screw. When the screw is driven
into the pubic bone of the patient, the surgical mesh is also
engaged and thereby attached to the patient's pubic bone, thus
firmly and predictably attaching the surgical mesh to the pubic
bone.
FIGS. 3-6 illustrate a second embodiment of the invention which is
preferably used to drive and extract staples. FIG. 4 shows a
preferred form of this embodiment, which is particularly suited for
extracting staples, but may also be used for driving staples. This
form of the embodiment comprises a shaft 40; a slide hammer 48
(used only for extracting staples); a hexagonal end cap 44, a
suitable flat-topped capscrew or the like; and a staple grasping
device or dispenser 42. The shaft 40 in this form of the embodiment
is generally about 18 inches in length, exclusive of the end cap 44
and the staple grasping device 42. The shaft of the embodiment in
FIG. 4 is longer than the embodiment shown in FIG. 3. The purposes
for the longer shaft are to accommodate the slide hammer 48,
allowing adequate length for its effective use, and to accommodate
larger patients where the shorter shaft would tend to prevent
effective use of the device.
A similar form of the device is shown in FIG. 3. This form is aimed
at driving staples. This latter form comprises the shaft 40, in
this case about 12 inches long; and the staple grasping device 42.
It may be desired to use the end cap 44 (not shown in FIG. 3, but
illustrated in FIG. 4) with this form of the device. The end cap
offers two advantages: (1) a broader surface to strike when driving
the staple into place; and (2) the tool is less likely to roll
while on the surgical tray.
FIG. 5 illustrates the staple grasping device with a Richards
orthopedic bone staple grasped in the jaws of the device.
FIG. 6 is a side elevational view of a Richards bone staple.
FIG. 7A illustrates the staple grasping device in its staple
releasing mode. The staple grasping device has a first end portion
which is flat and disk-shaped. The first end portion possesses a
transverse slot which is configured to grasp a staple. The staple
grasping device possesses a second end portion which is specially
adapted to aid in the grasping of the staple and also possesses a
threaded member which allows the device to be releasably attached
to the shaft.
FIG. 7B illustrates the staple grasping device in its grasping
mode. When the surgical device is screwed tightly onto the shaft,
the lands 50 contact the first end portion of the shaft. Then as
the device is screwed tighter onto the shaft, the central portion
of the staple grasping device is pulled toward the shaft, causing
the device to flex and the lobes 52 to grasp the staple. To release
the staple, the pressure on the staple grasping device is relieved
by loosening the staple grasping device from the shaft.
During normal operation, the surgical mesh illustrated in FIG. 1B
is positioned at the surgical site separately from the staple
driving device. Once in place, the staple driving device securely
grasping a Richards bone staple is placed with the sharpened points
of the surgical staple positioned at the apex of the angle formed
by the structural members as previously described. Using a surgical
hammer, the orthopedic staple is hammered into place. Thusly, the
surgical mesh is firmly and predictably attached to the patient's
pubic bone. Then using the purchase of the staple, the shaft is
unscrewed slightly from the staple grasping device, allowing the
staple grasping device to return to its release mode. Then, the
device is removed from the patient.
Following the attachment of the surgical mesh to the patient's
pubic bone, the peripheral edges of the surgical mesh are attached
to appropriate anatomical structures of the patient by means of
either sutures or staples.
FIG. 8A illustrates the anatomy relevant to practicing the present
invention as viewed through an endoscope. The parts of the anatomy
include the ilioinguinal ligament 60, epigastric vessels 62,
Hesselbach's triangle 64, rectus abdominis muscle 66, pubic
tubercle 68, lacunar ligament 70, Cooper's ligament 72, pubic ramus
74, iliac vessels 76, testicular vessels 78 and vas deferens 80. Of
particular interest are the sites of an indirect hernia 82, a
direct hernia 84, and a femoral hernia 86.
FIG. 8B illustrates the placement of the surgical mesh 32 over
three hernia defects and attached to the pubic bone by an
orthopedic screw. The diagonal structural member 34 is positioned
over Hesselbach's triangle 64 and the internal inguinal ring
(indicated by the site of an indirect hernia) 82. The vertical
structural member 36 extends toward the rectus abdominis muscle 66.
The mesh between the structural members protects the usual site for
a direct hernia 84. The mesh lateral to the diagonal structural
member protects the usual sites for both indirect 82 and femoral
hernias 86. The surgical screw 54 is shown fastened to the pubic
ramus 74.
The present invention may be used in either open or endoscopic
surgery.
Referring to FIGS. 8A and 8B and using an open surgical method,
following the reduction of the inguinal hernia, a specially adapted
piece of surgical mesh is mechanically fastened to the patient's
pubic bone. This may be done using either of the embodiments of the
invention described above. The surgical mesh 32 may be positioned
so that the first and longest structural member is positioned over
Hesselbach's triangle 64 and the internal ring 82. Once attached to
the patient's pubic bone, the structural members 34 and 36 attached
to the surgical mesh tend to help conform the mesh to the patient's
anatomy in the region of the hernia.
The peripheral margins of the surgical mesh may then be sutured or
stapled to the appropriate anatomy. The segment of the surgical
mesh proximate the first and longest structural member may be
sutured or stapled to the iliopubic tract (not shown) lateral to
the internal ring 82. The portion of the surgical mesh proximate
the mechanical fastener may be sutured or stapled to Cooper's 72 or
Poupart's (not shown) ligament. A third portion of the surgical
mesh proximate the second structural member attached to the
surgical mesh may be sutured or stapled to the undersurface of the
rectus abdominis muscle 66. Finally, a fourth portion of the
surgical mesh, being the superior edge of the mesh, may be sutured
or stapled to the undersurface of the transverse abdominis arch
(not shown). When suturing is preferred, Ethicon 2-0 suture may be
used for attaching the surgical mesh, using the interrupted method.
The surgery may then be completed in traditional fashion.
The endoscopic method is a bit more complex, as will be indicated
by the following example. The patient is first administered general
anesthesia and properly prepped and draped. A 1 cm. incision is
then made in the inferior aspect of the umbilicus and a Verres
needle is inserted into the peritoneal cavity. The peritoneal
cavity is insufflated to 14 min. mercury with CO.sub.2, the needle
removed and a 10/12 min. trocar sheath inserted into the peritoneal
cavity. The endoscopic camera is positioned through the trocar
sheath.
Two incisions are made at the edge of the rectus abdominis muscle
parallel to the umbilicus on the fight and left sides. The
incisions are about 1 cm. in length and are preparatory to
insertion of trocar sheaths. Using monitor vision, a 10/12 min.
trocar sheath is inserted into each incision. The patient is placed
in the Trendelenberg position and fight direct and indirect
inguinal hernias are observed.
A grasping forcep is placed in the left sheath and an endoscopic
scissor in the fight sheath. An incision is made in the peritoneum
lateral and superior to the internal ring 82 and extended
transversely across to the medial umbilical ligament (not shown)
and from there inferiorly to the pubic bone. The peritoneum is
immobilized by the avulsion technique, thereby reducing the
inguinal sac and thus exposing the femoral vessels (not shown), the
internal ring 82, Hesselbach's triangle 64, and the pubic bone.
A specially adapted 3.times.5 inch polypropylene mesh 32 and
surgical screw 54 contained within the previously described
surgical device are inserted through the umbilical 10/12 min.
trocar sheath and placed against the pubic bone at the upper rami
(represented by position of screw 54). The screw is driven into the
bone and the device withdrawn, thus unfolding the specially adapted
3.times.5 inch polypropylene mesh. The long diagonal structural
member of the mesh is positioned diagonally across the Hesselbach's
triangle 64 and internal ring 82. Using an endostaple device, the
mesh proximate to the first and longest structural member is
stapled to the iliopubic tract (not shown) lateral to the internal
ring. The margin of the surgical mesh proximate to the second
structural member is then stapled to the undersurface of the rectus
abdominis muscle 66 superiorly. The superior edge of the mesh is
stapled to the undersurface of the transverse abdominis arch (not
shown).
The previously dissected fold of the peritoneum (not shown) is
placed over the entire mesh and reperitonealized by stapling the
cut edges of the peritoneum to the upper portion of the previous
peritoneal incision.
Closure is done in traditional fashion.
Although several preferred embodiments have been described in a
fair amount of detail, it is understood that such detail has been
for purposes of clarification only. Various modifications and
changes will be apparent to one having ordinary skill in the art
without departing from the spirit and scope of the invention as
hereinafter set forth in the claims.
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